Rolfing® Structural Integration Health Intake Form

• As a client of Adam Nickamin, I personally accept and agree to pay my balance in full, as my responsibility, to Adam Nickamin at the time of service and do not hold my insurance responsible for any medical services provided by Adam Nickamin.
• I understand Adam Nickamin provides nontraditional rolfing consultations, therapies, and procedures that may not be covered by any private insurance, Medicaid, nor Medicare. If I choose to submit my a medical bill from Adam Nickamin, his associates, or his associated clinics to any insurance provider, I may accept any reimbursement from that insurer as a payment to myself directly but do not permit this insurer to set any fee for services provided by Adam Nickamin.
• I acknowledge that there is a 24-hour Cancellation Policy or 48 hours’ notice for Monday appointments. I understand that if I do not cancel 24 hours before my scheduled appointment, or do not show for my appointment, I accept the responsibility of being charged $75.00.
• I understand that it is my responsibility to make sure that my bills are paid in a reasonable time (no longer than 1 month from the date of treatment). Services that go unpaid for more than 1 month will be billed to my credit card on file, unless a payment plan has been agreed upon.
• I understand that should I not pay for services rendered, I may be responsible for all collection, court, attorney, and legal fees.

Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Protected health information may be disclosed or used for treatment, payment or health care operations.
• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
• The Practice reserves the right to change the Notice of Privacy Practices
• The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
• The patient may revoke his Consent in writing at any time and all future disclosures will then cease

I give my permission for Adam Nickamin to provide treatment as he determines if they are medically necessary. I acknowledge that I will have been given the opportunity to discuss the nature and purpose of the treatment; alternate methods of treatment; and the risks, complications and consequences associated with the administration of rolfing. These risks include but are not limited to: bruising, temporary increase in pain, inflammation, numbness, weakness or paralysis, or spinal headache. I further acknowledge that any questions I have regarding the procedure have been answered to my satisfaction and that I have been further told that any additional questions I may have will be answered. I have read (or have had read to me) the above consent. I fully understand that there is no guarantee of successful treatment has been implied. I understand that I am entitled to a copy of this consent form upon request. Your consent authorizes arbitration as a solution for any malpractice claims and waives all court involvement.